Healthcare Provider Details

I. General information

NPI: 1386883890
Provider Name (Legal Business Name): FRANKLIN FOREST PURCIFUL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2009
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N BELL ST
KOKOMO IN
46901-3072
US

IV. Provider business mailing address

620 N BELL ST
KOKOMO IN
46901-3072
US

V. Phone/Fax

Practice location:
  • Phone: 765-456-7330
  • Fax: 765-456-2018
Mailing address:
  • Phone: 765-456-7330
  • Fax: 765-456-2018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000844A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: